2014 AAPM Annual Meeting: Professional Symposium on Communicating Risk
What works (most of the time)
what doesn’t work (most of the time)
what always or never works
Cynthia H. McCollough, PhD, FAAPM, FACR
Professor of Medical Physics and Biomedical Engineering
Director, CT Clinical Innovation Center
Mayo Clinic, Rochester, MN
2014 AAPM Annual Meeting: Professional Symposium on Communicating Risk
DISCLOSURES
Research Support:
NIH
Other
EB 017095
Mayo Discovery Translation Award
EB 017185
Mayo Center for Individualized Medicine Award
EB 016966
Thrasher Foundation
DK 100227
Siemens Healthcare
HR 046158
RR 018898
Off Label Usage
None
2014 AAPM Annual Meeting: Professional Symposium on Communicating Risk
If your goal is to sell newspapers
(or scare patients)
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This always works
2014 AAPM Annual Meeting: Professional Symposium on Communicating Risk
Public response: Fear and anxiety
• Patients and family members are worried, seeking
expert help before and/or after exposures
• Parents in particular calling, in tears, about “what
they have allowed to be done to their child”
2014 AAPM Annual Meeting: Professional Symposium on Communicating Risk
Being dismissive never works
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“They don’t know what they’re talking about”
“Just trust me on this …”
“Don’t be so silly”
“You can’t possibly believe that garbage?”
“What, you’re afraid of turning into Spiderman?”
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2014 AAPM Annual Meeting: Professional Symposium on Communicating Risk
All other strategies are situational
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No perfect recipe for what “always” works
Treat individuals with respect and compassion
They are scared, likely have other health stressors
Identify primary concern
Based on concern, address 2 or 3 key points
– Stick to these primary points, phrased in different ways
– Don’t get into an exhaustive debate of the literature
– Don’t drill down into too many details
• Could either be confusing or distracting
• Stick to key points
2014 AAPM Annual Meeting: Professional Symposium on Communicating Risk
Key message: Big benefit, small (if any) risk
• Radiation does cause cancer at very high doses,
but at low doses, the effects are too small to be
measured, or do not exist
– References: radiation protection organizations
• You/your family member received low doses
– References: internal and published typical doses, and
patient-specific data from medical record
• The risk (if it exists at these low doses) is negligible
compared to the benefit of a necessary medical exam
– Give examples tailored to situation, with references such
as ACR appropriateness criteria
2014 AAPM Annual Meeting: Professional Symposium on Communicating Risk
Secondary message: You are in good hands
• Our facility
– uses age and size appropriate doses
– tailors the exam for the diagnostic task
– has advanced imaging devices with radiation dose
management features
– is accredited by ACR and JCAHO
– participates in national dose registry
– monitors our dose data closely
– has rigorous quality testing of equipment
– is staffed by board certified medical physicists
– all CT technologists have additional certification in CT
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2014 AAPM Annual Meeting: Professional Symposium on Communicating Risk
Case 1: Facebook inquiry
• … I was hoping to ease some anxiety about the conflicting
information re: cancer and radiation esp in children … 6 days old
son fell off bed … of course not being educated or told of the risks
of radiation they ordered a CT scan and spinal x-ray and we obliged.
• … The tech didn't want to do it saying it was A LOT of radiation
and now those words stick with me with along with the guilt that I
have given my son a cancer and death sentence.
• … I keep reading Dr. Internet about the risk of childhood cancers
like leukemia and lymphoma (which my dad had) and I am literally
sick to my stomach every day with worry. He has an enlarged lymph
node on his neck, this constant cough and although drs not
concerned, I have convinced myself it is linked to cancer
b/c of all these tests.
2014 AAPM Annual Meeting: Professional Symposium on Communicating Risk
Case 1: Facebook inquiry
• I don't know how to make peace with [our] decision to put him
through all these tests and can't convince myself that the risks
outweighed the benefit esp reading that most ERs do these tests to
cover their butts.
• ... I look at him all happy and playing and I fear I have caused him
future harm.
• … I wish I could turn back the hands of time and I would never have
put him through all this. He was so young and is only 3 now.
• … While I am definitely worried about the CT scan (total mAs 1301,
CTD1vo1 30.90, DLP (mGycm 417.50-not sure what these numbers
mean) I am also worried about the possible cumulative effect of all the
radiation from all the tests he has had [additional chest x-rays for
difficulty breathing and a barium swallow for reflux]
2014 AAPM Annual Meeting: Professional Symposium on Communicating Risk
Mother has bachelor and masters degrees
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2014 AAPM Annual Meeting: Professional Symposium on Communicating Risk
Case 2: Via telephone
• Senior scientist at major aeronautics engineering firm
• Regrets his choice to allow a head and neck CT scan to
be performed on him
• Looked up numbers (6 rem) and is appalled
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“Dose” of 60 mGy ~ 6R ~ 6 rem
“Effective dose ~ 1-2 mSv ~ 100-200 mrem
• Chance meeting in June. He thanked me for my help,
but proceeded to talk 30 minutes about his concerns
that docs perform CT scans when they don’t need to
• “He could have just told me to keep taking ibuprofen”
2014 AAPM Annual Meeting: Professional Symposium on Communicating Risk
Primary concern: Post-exam regret/fear
• Remind patient/family member that a negative exam is
not an “unnecessary” exam
• Inform re: consequences of not having the exam could
range from inconvenient (delayed treatment and healing)
to catastrophic (death from brain bleed, paralysis from
spinal cord injury due to broken vertebrae)
• Express happiness that the injury was not serious and glad
that the CT could “clear them” to go home safely
• I share personal story of my daughter, where the
“optional” CT prevented unnecessary emergency surgery
2014 AAPM Annual Meeting: Professional Symposium on Communicating Risk
Education level doesn’t matter
• People with more education, esp. physicians, can be the
most difficult to “re-educate”
• “Just trust me” isn’t effective
• Educated patients/family members have the skills to
seek out literature on the topic (Dr. Internet?)
• People tend to seek out data to support their opinion
• Don’t argue. Don’t debate the literature.
Do clarify misinformation (e.g. type of “dose”, units)
• Be familiar with current literature and prepared to cite a
few key references to support what you are explaining
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2014 AAPM Annual Meeting: Professional Symposium on Communicating Risk
Good article for physicians
2014 AAPM Annual Meeting: Professional Symposium on Communicating Risk
Case 3: Via e-mail
• Please forgive if contacting you in this way is way out
of line, but I am growing desperate for information
from a well- informed source.
• I had a pelvic CT scan with a gastrogravin enema ... I
felt so bad when I got home, about an hour and a half
later, that I laid down and fell asleep for two hours
(something I very rarely do). I awoke with a splitting
headache, primarily in the eyes, and then, about seven
hours after the procedure, I began to throw up
violently.
2014 AAPM Annual Meeting: Professional Symposium on Communicating Risk
Case 3: Via e-mail
• I guess this could have been a reaction to the
gastrogravin, but I called the facility that did the
procedure to find out if that could be the case and to
determine what my radiation dose had been. They said
the gastrogravin could not have such an effect
• They gave a Dose Length Product figure of 102.57
mGY. I was later given a 1.9 millesievert figure … but
the tech could not tell me how the two figures relate or
anything else about the procedure, except that one can't
even get radiation sickness from a medical procedure,
which brought little in the way of consolation.
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2014 AAPM Annual Meeting: Professional Symposium on Communicating Risk
Primary concern: Radiation poisoning
• Could you possibly tell me whether the 102.57
mGY DLP is high (I'm a 105lb. female)?
• I really need to know whether to seek treatment of
any kind.
2014 AAPM Annual Meeting: Professional Symposium on Communicating Risk
2014 AAPM Annual Meeting: Professional Symposium on Communicating Risk
Provide reassurance and logical explanation
• Did not start with “you can’t possibly have radiation
poisoning”
• Emails, facebook, other written communication allows
time to do your homework
– Checked drug information and spoke with a GI radiologist
• Offering a clear, logical explanation of “what caused
this” erased the radiation poisoning fear
• Reassured her that the dose numbers where very
reasonable/good and (then) assured her that her dose
(all imaging doses) was 100-1000 times below the level
where radiation poisoning occurs
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2014 AAPM Annual Meeting: Professional Symposium on Communicating Risk
Mayoclinic.org
2014 AAPM Annual Meeting: Professional Symposium on Communicating Risk
Case 4:
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84 y.o. male
Abdominal aortic aneurysm
Pre-surgical CT Angiogram ordered
NEJM article of dangers of CT is published
Leaves message for physician “requesting that his CT
‘with the cancer-causing stuff’ be changed to an
ultrasound”
• Physician requests that I contact patient so that he will
have the CT, as it is essential for surgical planning
2014 AAPM Annual Meeting: Professional Symposium on Communicating Risk
Primary concern: Refusing needed exam
• Explaining the CT exam and the information that
the doctor needs from it is a strong start
– Use 3D images if possible
– Explain stent graphs and how
they are custom fit
– CT let’s doctor “take
his measurements”
– US can’t do this with
same accuracy (show US image)
– US can’t see tiny arteries that
are critical to avoid
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2014 AAPM Annual Meeting: Professional Symposium on Communicating Risk
Benefit, benefit, benefit
Secondary messages about safety
of our practice were also helpful
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